Introduction of Postpartum Intrauterine Contraceptive Devices for Expanding Contraceptive Options for Postpartum omen in Ethiopia Authors: Assefa Alem, Tesfaye Garedew, Bereket Mathewes, Sanjida Hasan, Caitlin Shannon, Analee Etheredge ------

• While the World Health Organization recommends spacing pregnancies by at least 24 months, in Ethiopia, 21 °/o of births occur within 7 to 23 months of the previous births. Further, while postpartum family planning (FP) is internationally recognized as a critical intervention for reducing unmet need and decreasing maternal and child mortality and morbidity, 22o/o of women in Ethiopia have an unmet need for FP for spacing or limiting future births. • EngenderHealth collaborated with the Federal Ministry of Health (FMOH) to introduce an intervention aimed at improving access to postpartum FP counseling and services including specifically increasing uptake of postpartum intrauterine device (PPIUD) as an effective and efficient means to addressing spacing and limiting needs. EngenderHealth, with the FMOH, developed and piloted a PPIUD package in 28 government facilities across 4 regions and in Addis Ababa over a 2-year period (2014 to 2016). This package included: (1) clinical training and an intensive follow-up mentoring program on PPIUD insertion and removal for providers; (2) site orientations for clinical and nonclinical staff, health extension workers, and community workers to mobilize support and strengthen referral systems; and (3) equipping and supplying facilities with necessary materials.

• EngenderHealth collected data in a subset of treatment facilities: 8 high-volume and 8 low-volume facilities. More than 82o/o of trained providers (114) participated in the study. • The project collected baseline and endline facility data using structured and pretested data collection tools related to the following variables of interest: (1) time and place of postpartum FP counseling, (2) magnitude and timing of PPIUD insertion, and (3) monthly insertion rates by provider and facility. The project also collected data on provider competency and knowledge levels related to the training objectives. EngenderHealth conducted a univariate analysis and chi squared test to determine significance between baseline and endline statistics. • The project also collected qualitative data through semi-structured interviews with PPIUD providers, facility managers, and implementation staff at the 16 sampled facilities and analyzed this data using the •\ •. I, '•;A '.'I;' . conventional inductive approach. Zelemai:,· Production/EngenderHealth

• A total of 138 providers across the 28 project-supported facilities completed the clinical training. Figure 1. Timing of FP Counseling • The 16 sampled treatment facilities reported a total of 3,809 PPIUD insertions during the evaluation period. The 114 providers participating in the study performed 1,967 of these PPIUD insertions. On average, a provider inserted 1.26 IUDs per month. • With regard to timing of insertion, 81 °/o were performed within 10 minutes of delivery, 8°/o were performed between 10 minutes and 48 hours of delivery, and 1 o/o were performed during cesarean deliveries. • Of 3,809 PPIUD clients, most (approximately 47°/o) received FP counseling during the postpartum period or (approximately 44%) during labor and delivery, while others (approximately 4o/o) received counseling during antenatal visits or (approximately 4o/o) during multiple visits (see Figure 1 ). • Overall, the net improvement in provider testing following training was 41.4o/o.A vast majority of the trained providers (122 of 138) scored 80o/o or better on the first posttraining test, completed at the end of the training. The project also facilitated a second posttraining test within 6 months of the training. The mean score from the first posttraining test was 83°/o, compared with the mean score of 89o/o for the second posttraining test. ■ Postpartum Visit ■ Labor & Delivery Visit • The study also found that most trained providers felt confident providing FP counseling to ■ Antenatal Visit ■ Multiple Visits pregnant women and performing PPIUD insertions safely and effectively.

• The intervention proved successful in increasing postpartum FP, and EngenderHealth notes that the multidimensional approach-which included PPIUD clinical training in parallel with site orientations and resourcing-was critical to this success. • Furthermore, the combination of a comprehensive 10-day training and follow-up mentoring was essential for ensuring and institutionalizing provider competencies in PPIUD insertion. • EngenderHealth recommends considering facility caseloads in designing future PPIUD trainings to ensure as many staff as possible are able to routinely offer PPIUD services. • Few women received FP counseling during antenatal visits, representing a notable missed opportunity for reaching women with postpartum FP needs. Future interventions should focus on integrating FP counseling into antenatal care with the aim of improving postpartum FP uptake. • Additionally, few PPIUD clients returned for follow-up care (approximately 12o/o); thus limited data are available on IUD complications, expulsions, or infections. Future studies will need to include interventions to promote post-PPIUD insertion follow-up-for example, through linking community health workers with clients through a referral system-in order to track and treat any related complications.

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www.engenderhealth.org INTERNATIONAL CONFERENCE ON FAMILY PLANNING 2018